ATI Med-Surg Exam: Cardiovascular and
Hemoglobin
- A nurse is assessing a client who has late-stage heart failure and is experiencing
fluid volume overload. Which of the following findings should the nurse expect?
(ANS – Weight gain 1 kg (2.2 lb) in 1 day.
A weight gain of 1 kg (2.2 lb) in 1 day alerts the nurse that the client is retaining
fluid and is at risk of fluid volume overload. This is an indication that the client’s
heart failure is worsening. - A nurse is assessing a client who has an abdominal aortic aneurysm. Which of
the following manifestations should the nurse expect?
(ANS – Lower back discomfort
Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the
aorta. Back and abdominal pain indicate that the aneurysm is extending downward
and pressing on lumbar spinal nerve roots, causing pain. - A nurse is caring for a client who is in hypovolemic shock. While waiting for a
unit of blood, the nurse should administer which of the following IV solutions?
(ANS – 0.9% sodium chloride
Solutions of 0.9% sodium chloride, as well as Lactated Ringer’s solution, are used
for fluid volume replacement. Sodium chloride, a crystalloid, is a physiologic
isotonic solution that replaces lost volume in the blood stream and is the only
solution to use when infusing blood products. - A nurse is planning care for a client who has pernicious anemia. Which of the
following interventions should the nurse include in the plan?
(ANS – Initiate weekly injections of vitamin B12.
The nurse should initiate weekly injections of vitamin B12 for a client who has
pernicious anemia, and then decrease to monthly. Pernicious anemia is caused by a
lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract. - A nurse is administering a unit of packed red blood cells (RBCs) to a client who
is postoperative. The client reports itching and has hives 30 min after the infusion
begins. Which of the following actions should the nurse take first?
(ANS – Stop the infusion of blood.
The nurse should apply the urgent vs. nonurgent priority-setting framework. Using
this framework, the nurse should consider urgent needs the priority because they
pose more of a threat to the client. The nurse might also need to use Maslow’s
hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which finding is the most urgent. The nurse should stop the infusion of
blood because the client has manifestations of an allergic reaction. - A nurse is caring for a client who had a myocardial infarction 5 days ago. The
client has a sudden onset of shortness of breath and begins coughing frothy, pink
sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the
following adventitious breath sounds should the nurse document?
(ANS – Coarse crackles